Tinnitus

Overview

Tinnitus is the perception of sound without an external source. It is commonly described as ringing but can also manifest as clicking, buzzing, hissing, or roaring. While nearly everyone experiences faint tinnitus in a quiet room, it becomes a concern when it is bothersome, interferes with normal hearing, or is associated with other issues. The term tinnitus originates from the Latin word tinnire, meaning "to ring."

Signs and Symptoms

Tinnitus may be intermittent or continuous, and its intensity can vary. It can be perceived in one or both ears or from the head itself. The condition often accompanies hearing loss, making it difficult to comprehend speech, particularly in noisy environments. Tinnitus can be exacerbated by movements of the shoulder, neck, head, tongue, jaw, or eyes.

Psychological Effects

Persistent tinnitus can lead to anxiety and depression. The distress caused by tinnitus is more closely linked to the individual's psychological state rather than the loudness or frequency of the sound. Psychological issues such as sleep disturbances and concentration difficulties are common among those severely affected by tinnitus. Research indicates that the initial perception of tinnitus, conditioned with negative emotions like fear and anxiety, contributes to its severity.

Diagnosis

The diagnosis of tinnitus is primarily based on the patient's description of their symptoms. An audiogram and otolaryngological and neurological exams often support this diagnosis. If certain issues are identified, medical imaging such as MRI may be necessary. Questionnaires can quantify how much tinnitus disrupts a patient's life. When tinnitus coincides with the heartbeat, specific tests are required to rule out vascular causes.

Audiology

An audiogram helps diagnose tinnitus, especially when it is associated with hearing loss. The pitch of tinnitus often aligns with the range of hearing loss. Psychoacoustic measures, including frequency, loudness, and residual inhibition, can provide additional insights. Hyperacusis assessment, often linked with tinnitus, evaluates the discomfort level at various frequencies.

Types of Tinnitus

Subjective Tinnitus

Subjective tinnitus, the most common form, is perceived only by the patient. It often results from hearing loss due to cochlear injury, infections, drugs, or trauma. Long-term exposure to noise pollution may also increase the risk. In some cases, neuroplastic changes in the central auditory pathway, as a response to hearing loss, may cause tinnitus.

Objective Tinnitus

Objective tinnitus is rare and can be heard by others using a stethoscope. It may be due to muscle contractions, blood flow sounds, or spontaneous otoacoustic emissions (SOAEs).

Pulsatile Tinnitus

Pulsatile tinnitus coincides with the patient's pulse and is usually objective. It may result from altered blood flow or increased blood turbulence near the ear. Causes include vascular anomalies, tumours, middle ear or inner ear disorders, and intracranial pathologies.

Pathophysiology

Tinnitus may stem from increased neural activity in the auditory brainstem, with many sufferers also experiencing hearing loss. Reviews emphasise the wide range of pathologies involved, necessitating specifically adapted therapies.

Management

Psychological

Cognitive behavioural therapy (CBT) is the most effective treatment, reducing stress without directly affecting tinnitus. Acceptance and commitment therapy (ACT) and relaxation techniques also show promise. The US Department of Veterans Affairs has developed a clinical protocol called Progressive Tinnitus Management.

Sound-Based Interventions

Sound therapy, using hearing aids or tinnitus maskers, can help the brain ignore the tinnitus frequency. Tinnitus retraining therapy and mobile applications offering sound masking and relaxation exercises are potential interventions. Neuromonics therapy and bimodal neuromodulation also show promise.

Medications

As of now, no medications are effective for idiopathic tinnitus. The effectiveness of antidepressants, anticonvulsants, and other drugs remains unclear. Injections of botulinum toxin have been successful in rare cases of objective tinnitus due to muscle spasms.

Prevention

Preventing tinnitus involves avoiding prolonged exposure to loud noises and ototoxic medications. Custom-made earplugs can protect against noise-induced hearing damage. Certain occupational groups, including military personnel, musicians, and construction workers, should take additional precautions.

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Self-assessment MCQs (single best answer)

What is tinnitus?

Which of the following is a common psychological effect of persistent tinnitus?

What is the primary method for diagnosing tinnitus?

Which type of tinnitus is most commonly perceived only by the patient?

What is the most effective psychological treatment for tinnitus?

What is often used in sound-based interventions for tinnitus management?

Which of the following is not a potential cause of objective tinnitus?

What does an audiogram help diagnose in relation to tinnitus?

What is a recommended prevention strategy for tinnitus?

Which of the following is not a common description of tinnitus sounds?